Kinney, Neata . TO WN of QUEEMs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEFNSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director r9,Z,�x _--
N a m e/V?C T/g Case #
Date of Cremation z— oZ 7 "
Time Cremation Started 40 Y52 d/M
Time Cremation Completed .t
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Type of Container lS—yi I
Remarks :
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DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
• t�
If pulverization of cremated remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will or open Sundays,cremations 5 days a week 7:00 A.M. -arrangements can be made for Saturday.O Monday-
Friday. No Holidays
by telephone for acceptance of remains is necessary.`
2. Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road,
Town of Queensbury. �
3. An authorization for cremation properly signed by the nearest next of kin or other authorized
e cremation of the
person stating that they do have the power and authority to arrangehan r therso al possessions
remains and to direct the disposition of the cremated remains, Y P I
have either been removed or may be destroyed and agree to protect, defend and save
harmless Pine View Crematorium from any and all claims and demands for loss or damages
which may be made against them by reason of or connected with the cremation of said
remains and/or disposition of said remains as directed, whether such claims demands
are,
toj
or are not wholly groundless, false or fraudulent. This authorization in addition
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable alternate container. Caskets and
containers must be of combustible material. No Styrofoam or plastic containers will be
accepted.
5. The question relative to cardiac pacemakers must be answered on the authorization to
cremate form before the remains will be accepted.
filed via Re istered I
6. Unless other arrangements are made the cremated remains will be ma 9
U.S. Mail within three days of cremation to the funeral home handling the service. There will
be a $25.00 charge for this service.
13 months to
Recording Fee: Adult$300.00 Children (age
Cremation, Administration Costs an g
Crema d Reco
12 years) $150.00 Infants stillborn to 12 months) $100.00
Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
ed the additional$50.00.
Cremations done on Saturdays will be charged
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM `1
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
Neata Kinney Female
(NAME) (SEX)
Adirondack Manor, 440 Bay Rd. , Queensbury, New York 12804
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 25th day of June 20 02
at Eden Park Health Care Center Warren St. Glens Fall
s, NY 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Richard L. Kinney, 29 Midline Rd. , Ballston Lake, NY 12019
Relationship to deceased Grandson
Name of Funeral Home Alexander Funeral Home Inc. Warrens r
IMPORTANT
I represent that to the best of my knowledge, the deceased has no pacemaker in her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any a II claims and demands for loss or damages which may be made
against them by reason f r connected with the cremation of said remains as directed, whether
such cla* or dRmand ar or are not wholly groundless, false or fraudulent.
aniel J. Gravel 3
( ESS) (A DRESS)
Same as above
(SIGNATURE OF 14ELATIVE OR GAL REP. AND ADDRESS)
S ned on this date.
6-26-02